CIRCUIT COURT OF ST. LOUIS COUNTY STATE OF MISSOURI NEUTRAL QUALIFICATION FORM Pursuant to Local Rule 38 I am applying for inclusion on the list of neutrals to be maintained by the Circuit Clerk pursuant to Local Rule 38 of the Circuit Court of St. Louis County. The following information is supplied in support of this application. 1. Name: (Last) (Middle) (City) 2. (First) (State) (Zip+4) Address: 3. Telephone Number: 4. Facsimile Number: 5. State the standard hourly fee for your services as a neutral. 6. List your appropriate training or equivalent experience in conducting alternative dispute resolution as required for certification under Supreme Court Rule 17.04. 7. Please list all areas of substantive law or experience which are or have been a significant part of your professional background or practice. CCDT232 01/09 American LegalNet, Inc. www.FormsWorkflow.com 8. [If the answer to any of the following questions is yes, please explain the circumstances on a separate sheet and attach.] a. Have you ever been disciplined for violation of any code of professional ethics or responsibility? b. Have you ever pled guilty to or been found guilty of a felony? c. Have you ever been found liable for fraud or any other intentional tort? d. Have you ever had a professional license revoked or suspended for reasons other than non-payment of dues? e. Have any professional malpractice judgments been entered against you? 9. List the courts and professional organization in which you currently hold certifications as a neutral, mediator, arbitrator, or other ADR service provider. 10. In the space below, briefly describe your experience, qualifications, special areas of expertise, and any other reasons why you should be selected as a neutral. (Signature) (Date) THIS FORM WILL BE MADE AVAILABLE TO THE PARTIES TO ASSIST THEM IN CHOOSING A NEUTRAL. CCDT232 01/09 American LegalNet, Inc. www.FormsWorkflow.com